MEDICARE: MS. EDITH C MACDOUGAL RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0400X	Case Management Registered Nurse	70380030	WI

General Provider Information

NPI Number	:	1184840423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. EDITH C MACDOUGAL RN

Provider Business Mailing Address
First Line	:	1407 ST. ANDREW ST.
Second Line	:	SUITE 100
City	:	LA CROSSE
State	:	WI
Zip	:	54601-4002
Country	:	US
Telephone Number	:	608-785-5939
Fax Number	:	608-785-6315

Provider Business Practice Location Address
First Line	:	1407 ST. ANDREW ST.
Second Line	:	SUITE 100
City	:	LA CROSSE
State	:	WI
Zip	:	54601-4002
Country	:	US
Telephone Number	:	608-785-5939
Fax Number	:	608-785-6315

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	07/08/2007

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